tci General Surgery Coding Alert - 2016 Issue 12

Reader Question: 'Extensive Undermining' Points to Repair Choice

Question: A patient presented with a deep, ragged, debris-filled wound on her abdomen from falling onto a decaying fence with rusty metal parts. The surgeon’s report documents a 7.0 cm layered closure “with extensive undermining.” Is this enough to bill a complex repair? SuperCoder Subscriber Answer: Yes, based on what you describe the appropriate code would be 13101 (Repair, complex, trunk; 2.6 cm to 7.5 cm). The layered closure coupled with documented “extensive undermining” justifies selecting a complex repair code instead of intermediate repair. Better: However, the surgeon’s documentation could improve...

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